E&M Documentation Requirements, Part 3: The Chief Complaint and Elements to the History of the Present Illness

Ophthalmologists are more likely to be audited on exam documentation than on tests or surgical procedures. It is therefore imperative that documentation meets the payer requirements each time an exam code is billed. This month, we’ll look at the chief complaint and elements of the history of the present illness. These two components provide the reason for the encounter and indicate what elements of the exam are medically necessary to perform.

E&M documentation includes the history, exam and medical decision making. Over the last two months, YO Info has taken a look at the first two portions of the history component, review of systems and past, family and social history. This month, we’ll look at the third and final piece of the puzzle, the chief complaint and elements of the history of the present illness. These two components provide the reason for the encounter and indicate what elements of the exam are medically necessary to perform.

Chief Complaint

The chief complaint is the focus of the exam. If the patient has several complaints, document them in order of highest to lowest medical risk. For example, consider the elements of the exam performed when the patient complains of red eyelids that itch, and compare them to the elements of the exam performed when the second complaint is that the vision in the left eye has become progressively worse over the past month. Because the second complaint might carry the greatest medical risk, it should be listed first.

Note: When the primary diagnosis is blepharitis, commercial payers might downcode a higher level of exam.

The chief complaint does not have to be documented in the patient’s own words unless it provides helpful information, such as in the complaint of dry eyes: Eye discomfort OU X 2 wks. Feels like “crushed potato chips.” Artificial tears and ointments no lasting relief.

History of the Present Illness

The history of the present illness HPI provides a chronological description of how the patient’s present illness developed, from the first sign or symptom to the present.

CPT guidelines recognize the following eight components of the HPI:

Location. What is the site of the problem? Is it unilateral or bilateral?

Quality. What is the nature of the pain? Is it constant, acute, chronic, improved or worsening?

Severity. Describe the pain or redness, for example, on a scale of 1 to 10, with 10 being the worst.

Duration. How long has the problem been an issue?

Timing. Is the problem worse in the morning or evening, or is it constant?

Context. Is it associated with any activity?

Modifying factors. What efforts has the patient made to improve the problem? Heat? Artificial tears? Other?

The HPI is brief if one to three elements are documented and extended if four to eight elements are documented. CPT codes 99204, 99205, 99214 and 99215 all require an extended HPI.

Negative responses count when they are pertinent to the chief complaint, such as in the example of growths below. Negative responses don’t count when they are not pertinent to the chief complaint and/or are often cloned from exam to exam e.g., the case of floaters below.

CC: Floaters OU HPI: No headache, no itching, no tearing not signs/symptoms associated with CC.

X

CC: Patient complains of red eye. Began two days ago duration. Limited to right eye location. Worse in the morning timing. Lids are stuck shut with discharge associated signs/symptoms.

X

Chronic or Inactive Conditions For established patients only, documenting the status of some chronic or inactive conditions may qualify for an extended HPI. For example, the patient complains of:

Cataracts: distance vision worse since exam six months ago.

Dry eyes: condition improved with consistent use of artificial tears.

Blepharitis: condition improved with lid scrubs.

Audit Outcomes

As reported to the Academy, inadequately documented history components were the primary reason payers downcoded claims in an audit. The chief complaint, HPI, review of systems and past, family and social history all must be documented to support the level of E&M code you submit.

To have your own examples of CCs and HPIs checked for audit review, email coding@aao.org with subject line “YO Info.”